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					Care Providers of Minnesota established a new Quality Council in 2010 to act as both the
funnel and guide for the Association’s quality agenda.

In 2011, the Council expanded their initial charge by developing resources for members that
would advance our quality agenda such as the quality dashboard tool, and by more closely
integrating our efforts with the quality agenda of the American Health Care Association/
National Center for Assisted Living (AHCA/NCAL). The work of the Council has expanded, as
opportunities presented themselves throughout the year.

In 2011, we continued producing the resources established by the Council in its inaugural
year, including the quarterly electronic newsletter, Quality in Action; focused presentations at
our seminars and annual convention; and this second annual quality report. We invited guest
speakers to our Council meetings for presentations and discussions on quality-related topics
such as developing indicators, new performance data analysis, and quality incentives.

One of the driving forces behind the Council and this report is the knowledge that members
of this Association are committed to quality improvement as a process leading to improved
outcomes for the tens of thousands of customers served daily in our organizations. We con-
tinue to learn from each other, from our partners in quality, and from evolving best practices.

Similar to our 2010 report, we hope you use this report as we have conceived it:

       As a reminder of the various “success stories” we experience daily in our profession
       As an idea-starter and motivator to help you innovate in your quality improvement
       efforts
       As a resource describing various state and national initiatives designed to help you in
       your quality journey

Because we know that quality improvement is ongoing, we thank you for joining us on this
journey, and for your interest and passion for quality. And, as always, we welcome your input
and feedback at any time.




Gail Sheridan                Mark Anderson                         Patti Cullen
Chair, Board of Directors    Chair, Quality Council                CEO/President
2010–2011                    2010–2011
Nursing home survey trends                                                   p. 4
Long-Term Services and Supports Scorecard results                            p. 5
Partnerships for reducing rehospitalizations                                 p. 6
NCAL performance measurement initiative                                      p. 7
Care Providers of Minnesota receives quality award                           p. 8
Guest speakers share the Quality Council journey                             p. 9
Performance-based incentive program (PIPP) highlights                        p. 9
Members receive national recognition for excellence                          p. 10
Performance excellence in three simple questions                             p. 12
Nursing homes participate in QAPI project                                    p. 15
Advocating for quality in 2011                                               p. 16
Nursing facility quality dashboard                                           p. 19




Established in 1947 as a supportive partner to nursing homes, Care Providers of Minnesota now
serves the needs of providers across the entire spectrum of long-term care. As a statewide, nonprofit
trade association, Care Providers of Minnesota represents over 600 proprietary, nonprofit, and
government-owned providers of long-term care including nursing facilities, housing with services,
assisted living, adult foster care, home care, and hospice.

Our membership includes providers ranging in size from three beds to 400; and includes over 100
business partners who actively support the Association and its members.




  Residents from Minnesota Masonic Home in Bloomington are proud of their facility’s 2011 AHCA/NCAL
  Bronze Quality Award!
The Minnesota Department of Health (MDH) was one of                   The most recent data puts the number of deficiencies is-
the first state survey agencies to begin using an alternative         sued per survey in Minnesota almost equal to the average
nursing home survey process known as the Quality Indica-              issued in the nation.
tor Survey (QIS). MDH began training surveyors and utiliz-
ing the QIS process in 2007, and became a 100% QIS                    A common problem prior to the implementation of QIS in
process state in 2010. Currently there are only 11 states             Minnesota was the variance in the number of deficiencies
who are 100% QIS, with more on the way.                               issued by surveyors based on where the survey teams
                                                                      were located within the state. Some areas of the state rou-
                                                                      tinely issued twice as many deficiencies as other areas of
  The QIS process was designed to achieve four
                                                                      the state. We believe that the QIS process has minimized
  objectives:
                                                                      some of this discrepancy and are working with MDH to
  1. Improve consistency and accuracy of the survey
                                                                      determine if this is accurate.
  2. Comprehensively review more regulatory areas
     within current survey resources                                  The QIS process, however, has increased the percentage
  3. Enhance documentation through automation                         of surveys with findings considered “Substandard Quality
                                                                      of Care” (SQC). A provider is cited as providing SQC if it
  4. Focus survey resources on facilities with the                    receives a deficiency in one or more of the following com-
     greatest quality concerns                                        pliance categories: Quality of Care (21 different require-
                                                                      ments); Quality of Life (18 different requirements); or Resi-
                                                                      dent Behavior and Facility Practices (6 different require-
Prior to QIS, Minnesota routinely had the reputation of               ments)—and either the findings are widespread with no
being a state that issued many more deficiencies than                 actual harm but with the potential for more than minimal
other states. We were also one of the few states that                 harm, or actual harm occurred.
“cross referenced” survey deficiencies…meaning one
finding or observation could result in 3–5 different survey           Prior to QIS, Minnesota tended to have fewer surveys with
deficiencies.                                                         SQC results (usually less than 3% of all surveys), while
                                                                      QIS surveys have found Minnesota providers receiving a
The QIS process, however, uses computerized algorithms                slightly higher percentage of SQC findings (3%–5%),
and resident survey results to help guide surveyors toward            which is slightly above the national average.
the most appropriate deficiencies. What has been the re-
sult of the QIS process in Minnesota? We have seen al-                Providers, regulators, and nursing home residents have
most a 40% drop in the average number of deficiencies                 generally shared that they all prefer the QIS process over
issued per survey. Prior to QIS, nursing home providers               the more subjective traditional survey process. As a
were averaging around 10 deficiencies per survey; post-               bonus, it appears that the QIS process more closely aligns
QIS the number is closer to six.                                      survey results in Minnesota with those of the nation.


     Five-Star Rating: Minnesota versus the Nation
     40.00%

                                                                                       HOW DO WE COMPARE?
     30.00%
                                                                              The Centers for Medicare & Medicaid Services
     20.00%                                                                   (CMS) created the Five-Star Quality Rating
                                                                              System to help consumers, their families, and
                                                                              caregivers compare nursing homes more
     10.00%                                                                   easily and to help identify areas in which to
                                                                              ask questions.
      0.00%
                1 Star      2 Star       3 Star       4 Star       5 Star     A five-star home is considered “much above
                                                                              average quality” and those with one star,
               Overall Five-Star Rating - Minnesota (November 2011)           “much below average.”
               Overall Five-Star Rating - Nation (November 2011)
A report released in September 2011 by AARP’s Public           choice and control over their lives, thereby maximizing
Policy Institute, the Commonwealth Fund, and the SCAN          their independence and well-being.
Foundation showed some states significantly outperform
others in the delivery of long-term services and supports      Minnesota results
(LTSS) to older adults and people with disabilities—with       The Scorecard examines state performance across four
Minnesota ranking overall top in the nation!                   key dimensions of LTSS system performance. Each
                                                               dimension is composed of three to nine data indicators, for
The report, Raising Expectations: A State Scorecard on         a total of 25 indicators. All 50 states and the District of
Long-Term Services and Supports for Older Adults, People       Columbia were ranked; Minnesota’s scores are as follows:
with Physical Disabilities, and Family Caregivers (Raising
Expectations), finds however, that even the top three          Overall #1. On the individual key dimensions, Minnesota
states—Minnesota, Washington and Oregon—have a long            scored as follows:
way to go to create a high-performing system of LTSS. It           Affordability and access: 4
shows that all states need to vastly improve in areas              Choice of setting and provider: 3
including home care, assisted living, nursing home care,
                                                                   Quality of life and quality of care: 4
support for family caregivers, and more efficiently spending
                                                                   Support for family caregivers: 4
the funds they currently allocate to LTSS.

                                                               Minnesota ranked at the highest level across all four
Raising Expectations finds that generally states with the
                                                               dimensions of LTSS system performance.
highest level of performance, such as Minnesota, have
enacted public policies designed to:
                                                               The report identifies two services that help consumers
     Improve access to services and choices in their
                                                               understand all of their LTSS options: a single point of entry
     delivery by directing state Medicaid programs to
                                                               system available through Senior LinkAge Line; and Long-
     serve more people in need and offer alternatives to
                                                               Term Care Consultation Services, available through county
     nursing homes as most consumers prefer.
                                                               human services agencies.
     Establish a single point of system entry to help
     people find needed information and more easily            While Minnesota scored in the top quartile for 15 of the
     access services.                                          indicators, it was in the bottom quartile for one of the
     Improve support for family caregivers by offering         indicators, with the “lowest” rankings for:
     legal protections as well as other services to address        Percent of home health patients with a hospital
     caregiver needs.                                              admission (37th);
                                                                   Percent of nursing home residents with low care
Raising Expectations is designed to help states improve
                                                                   needs (32nd); and
the performance of their LTSS systems so that older peo-
ple and adults with disabilities in all states can exercise                                            continues on page 19


                                                                                   Staff from The Commons on
                                                                                   Marice, an assisted living
                                                                                   community in Eagan, pose for a
                                                                                   “photo op” after receiving the
                                                                                   Excellence in Assisted Living
                                                                                   Award at the 2011 Care Providers
                                                                                   of Minnesota convention.

                                                                                   Only three assisted living
                                                                                   communities in Minnesota have
                                                                                   been the recipient of this
                                                                                   prestigious award.
The Institute for Clinical Systems Improvement, the Minne-   RARE Campaign steering committee and various work
sota Hospital Association, and Stratis Health launched a     groups since its inception because of the critical role our
statewide campaign August 1, 2011, known as the RARE         members play in successful transitions.
(Reducing Avoidable Readmissions Effectively) Campaign.
The Campaign recognizes that avoidable hospital readmis-     While there are many (very individualized) reasons why
sions are the result of a fragmented health care system.     patients are readmitted into hospitals, there are some com-
RARE seeks to build upon and expand the work that has        mon themes that have emerged during these discussions.
been going on for several years by many hospitals, health    Some of these issues are being addressed through the
systems, long-term care providers, health plans, and other   resources and best practices being developed by the
community partners.                                          RARE Campaign and available on their website at
                                                             www.RAREreadmissions.org. Other factors are being
The RARE Campaign is focusing on five key areas that are     addressed by developing tools for tracking the incidence
known to be the main contributors to avoidable hospital      and prevalence of avoidable rehospitalizations by a
readmissions:                                                nursing facility.
    1. Comprehensive discharge planning
    2. Medication management                                 The RARE Campaign used a long-term care task force to
    3. Patient and family engagement in discharge            develop a user-friendly tracking tool (shown below with
       preparation                                           sample data) and to train long-term care providers on how
    4. Transition care                                       to use this tool via a free webinar. Many providers are also
    5. Transition communications                             participating in an intensive training program using the web
                                                             -based INTERACT (Interventions to Reduce Acute Care
Care Providers of Minnesota has been participating on the    Transfers) tools.
                                                                        continued


It has been evident from the beginning of the discussions                launch of a demonstration project focused on reducing
that long-term care providers need to continue to work                   preventable inpatient hospitalizations among residents
with their acute care partners to identify how to collaborate            of nursing facilities.
better to reduce avoidable hospital readmissions. We con-
tinue to give input to our partners in the discussions as          3.    There are new quality assurance and performance
various tools/processes are being developed, and we also                 improvement (QAPI) provisions for nursing homes in
are stressing how important managing hospital readmis-                   the 2010 Affordable Care Act. CMS described the
sions is for long-term care providers, not just for hospitals.           design and scope of a QAPI program, and indicated
                                                                         that when fully implemented, a QAPI program should
Here are some key reasons why it is important for nursing                address clinical care, quality of life, resident choice,
facilities to track hospital admissions/readmissions:                    and care transitions.
1. While many admissions/readmissions are necessary,
      many are avoidable. Preventable hospital admissions/         4.    CMS currently provides public reporting for hospitals
      readmissions place a significant burden on patients                and home health agencies on readmissions and
      and their families. Avoiding these transfers will                  admissions, respectively. Public reporting on this topic
      alleviate the burden they place on patients and their              for nursing homes could occur in the future.
      families and will allow them the comfort and well-being
      of sleeping in their own beds.                               5.    In 2012, hospitals will have financial risk for readmis-
                                                                         sions related to selected conditions, per provisions in
2.     The Centers for Medicare and Medicaid Services                    the Patient Protection and Affordable Care Act. It will
       (CMS) and other payers are increasingly interested in             be beneficial for nursing homes to be able to demon-
       improving coordination of care and focusing on the                strate to hospitals that they can help prevent avoid-
       topic of avoidable hospitalizations (avoidable hospitali-         able readmissions, by successfully and effectively
       zations are very costly). CMS recently announced the              managing care.




     Released in September 2011, the National Center for Assisted Living (NCAL) Performance Measures survey
     measures nine operational areas for Assisted Living Communities (ALC) dealing with resident and family satisfac-
     tion, employee satisfaction, resident occupancy rates, use of resident and family councils, use of mission and
     vision statements, implementation of safety programs, levels of nurse availability, and criminal background checks
     for new staff members.

                                                                                        According to the report, while
                                                                                        the percent of Minnesota’s
                                                                                        assisted living communities that
                                                                                        measure resident and family
                                                                                        satisfaction is similar to Midwest
                                                                                        and national cohorts, Minnesota’s
                                                                                        assisted living communities
                                                                                        measure employee satisfaction
                                                                                        at a higher rate.

                                                                                        The full study may be viewed at
                                                                                        www.ahcancal.org (just type
                                                                                        “Assisted Living Performance
                                                                                        Measures” in the search box).
Care Providers of Minnesota was one of five pilot state           and legislative tours; and 7) increased participation in vari-
affiliates selected by the American Health Care Associa-          ous quality initiatives including the AHCA/NCAL Quality
tion/National Center for Assisted Living (AHCA/NCAL) to           awards, Care Providers of Minnesota awards program,
participate in their National Quality Awards—the goal being       Advancing Excellence in America’s Nursing Homes, and
demonstrated involvement in promoting quality improve-            Minnesota’s Performance Incentive Payment Program.
ment among its members. Association staff completed a
first draft of the bronze application and the Quality Council     Examples of key changes taking place today affecting
offered input at their first meeting in 2011. Care Providers      Care Providers of Minnesota’s competitive situation
of Minnesota received word they were the recipient of the         include: (1) the evolving payment and regulatory environ-
bronze level award for state affiliates based on the applica-     ment for our housing and home and community-based
tion submitted in first quarter 2011.                             services (HCBS) membership as the state continues to
                                                                  rein in the expenditure growth in this area; (2) ongoing
While much of the award application mirrored the applica-         state budget structural deficits with rate and program
tion individual facilities provide for their AHCA/NCAL            reductions that result in decreased available revenue for
quality awards, there were a few adaptations made in the          members to spend on Care Providers of Minnesota activi-
application; and Association staff recommended other              ties; (3) implementation of various health care reform
changes as part of the process as a pilot state. Consistent       provisions that will change the relationships between older
with the facility applications were the application sections      adult service providers, hospitals, and health plans;
relating to organizational situation.                             (4) increased expectations for quality metrics and pay for
                                                                  performance measures for all providers along the
Here are a few excerpts from our “winning” submission:            spectrum of older adult service delivery; and (5) demo-
Operational success for Care Providers of Minnesota is            graphic trends including increased numbers of seniors
determined via outcomes measured against performance              over age 85, decreasing workforce impacting state tax
goals developed through our annual strategic planning             revenues, and decreasing worker availability, particularly
process: 1) increased member recruitment and retention;           in rural communities.
2) diversification of Association’s operational budget by
expanding non-dues revenue sources; 3) expansion of               Each of these changes provides Care Providers of Minne-
Service Corporation products to meet evolving member              sota opportunities to: 1) develop resources for members;
needs; 4) sustainability of Foundation funds to continue          2) develop advocacy tools that will help members tell their
with scholarship awards at current or increased levels; 5)        story; 3) determine how to quantify state savings for pre-
increased participation by volunteers on our committees           vention actions; 4) establish new collaborations with hospi-
and affiliated boards; 6) increased participation in member-      tals and clinics; 5) establish dashboard measures for
ship grassroots advocacy including “rolling” days at the          members to more easily interpret internal outcome meas-
Capitol, hosting candidate forums, donations to our PAC,          urement systems.


                                              Joy Ferguson, Golden          Strategic Context: One strategic challenge Care
                                              LivingCenter—Olivia, is       Providers of Minnesota faces is the lack of solid,
                                              the recipient of the 2011     consistent, and reliable data from our HCBS
                                              Aide—Caregiver of the         membership to be able to effectively advocate for
                                              Year award.
                                                                            their cost-effectiveness as a service delivery op-
                                              An extraordinary care-        tion; and to effectively defend against additional
                                              giver, Joy has dedicated      regulatory oversight and Medicaid rate reduc-
                                              her life to helping others.   tions. A second strategic challenge is the lack of
                                              For over 32 years, she
                                              has demonstrated that         financial resources, data sources and staff exper-
                                              caring comes from             tise to guide members toward successful soft-
                                              the heart.                    ware and technological integrations with other
                                                                            sectors of the healthcare system for improved
                                              Accompanying Joy
                                              is Mandy Gentilli,            transitions, improved quality outcomes, and de-
                                              administrator at Olivia       creased hospital readmissions. It is critical for
                                              (who also nominated           Care Providers of Minnesota to address these
                                              Joy for this award!).         challenges.
Throughout 2011, the Quality Council invited external part-
ners to join them at their meetings to either give input into
                                                                The Minnesota Department of Human Services (DHS)
specific initiatives or to learn more about quality improve-
                                                                published the inaugural edition of the Quarterly
ment activities that were underway. Whatever the reason,
                                                                Update for the Minnesota Nursing Facility Perform-
the learning exchange was reciprocal:
                                                                ance-based Incentive Payment Program (PIPP).

    Representatives from My InnerView presented pack-
                                                                The Quarterly Update contains articles on:
    age options available to members to track their quality
                                                                    The 2011 Summer PIPP Conference
    data, and described various features of each of the
    menu options. Numerous improvements have been                   Best practices
    made to data options, including custom and modifiable           A new and soon-to-be released PIPP social
    questions on surveys to fit specific organizations and          networking site
    online availability of surveys and tools.                       A feature on the St. Elizabeth’s Nursing Home
                                                                    and Health Care Center PIPP project on culture
    Staff from the Minnesota Board on Aging (BOA)                   change
    discussed quality measures being considered for
    home and community-based services; report cards             On October 17, 2011, DHS issued the sixth annual
    found on www.minnesotahelp.info were also dis-              request for proposals (RFP) for nursing facility
    cussed. The Council expressed concerns about some           performance-based incentive payments. Since July 1,
    of the measures, noting the report cards don’t neces-       2006, nursing facilities may contract with the
    sarily measure quality from a consumer’s point of           Department to earn performance-incentive Medical
    view. The Council’s input was well received, and we         Assistance (MA) payments of up to five percent of the
    anticipate another review and discussion as the             operating payment rate.
    project advances.
                                                                The incentive payments are time-limited rate adjust-
                                                                ments. DHS will implement the sixth round of perform-
    Stratis Health reported on several initiatives:
                                                                ance-based incentive payments on or after July 1,
       Minnesota Alliance for Patient Safety (MAPS):
                                                                2012. Funding available to implement new projects
       Currently the program is hospital-focused but there
                                                                under this provision for fiscal year ending June 30,
       is an interest to expand into long-term care with a
                                                                2013, is equal to approximately $2.4 million (state
       road map into patient safety culture with six
                                                                share).
       domains: leadership, justice, communication,
       teamwork, learning, and patient/resident/family          (To view the PIPP Quarterly Update, go to
       engagement.                                              www.dhs.state.mn.us and type “PIPP” in the keyword
        QAPI: The Centers for Medicare & Medicaid               search box.)
        Services has contracted with the University of Min-
        nesota and its subcontracting partner, Stratis
                                                                        4. Improving health for populations and
        Health, to conduct a demonstration project that will
                                                                           communities
        develop and test materials to form a national qual-
        ity assurance and performance improvement
                                                                  Staff from the Department of Human Services (DHS)
        (QAPI) rollout.
                                                                  presented on a quality indicators (QI) project for nurs-
        10th Scope of Work for the Quality Improvement            ing facilities. DHS has accumulated QIs from health
        Organization: The 10th scope of work for the QIO          plans to analyze performance/improvement. DHS has
        runs from 8/1/11–7/31/14 with the following four          data that allows them to do many cost comparison
        aims:                                                     cuts. The results of their initial data analysis showed
            1. Beneficiary and family centered care               surprisingly little difference in performance between
            2. Improving individual patient care                  health plans. The overall goal is for health plans to
            3. Integrating care for populations and               look at data for the facilities they work with, and pick
               communities                                        QIs to improve with facilities that score lower.
Through their progressive quality award program, the             Cerenity Care Center on Dellwood Place
American Health Care Association and the National Center         Cerenity Care Center, Residence & TCU on Humboldt
for Assisted Living (AHCA/NCAL) provide a pathway for            Cerenity Senior Care–Marian of St. Paul
long-term care providers to journey toward performance           Country Manor Health Care Center
excellence.                                                      Country View Senior Living Community
                                                                 Evergreen Terrace in Grand Rapids
AHCA/NCAL’s award program consists of three levels; first        Galtier Health Center
is the Bronze—the Commitment to Quality; next is the             GlenOaks Senior Care Campus
Silver—Achievement in Quality; and then the Gold—                Golden LivingCenter – Bloomington
Excellence in Quality. Facilities must first achieve a Bronze    Golden LivingCenter – Delano
award in order to progress to the Silver, and then the Gold.     Golden LivingCenter – Franklin
                                                                 Golden LivingCenter – Hopkins
Care Providers of Minnesota is proud of its members and          Golden LivingCenter – La Crescent
their commitment to quality. Since 1997, 101 have                Golden LivingCenter – Lake Ridge
achieved the Bronze level; 20, the Silver level, and four        Golden LivingCenter – Lynwood
have reached the Gold level. (Note: Minnesota has been           Golden LivingCenter – Moorhead
the recipient of more Gold quality awards than any other         Golden LivingCenter – Olivia
state! Of the 11 presented nationwide, four have gone to         Golden LivingCenter – Rochester East
Minnesota members!)                                              Golden LivingCenter – Rochester West
                                                                 Golden LivingCenter – Rush City
Note: italics indicates 2011 recipients                          Golden LivingCenter – Slayton
                                                                 Golden LivingCenter – Twin Rivers
BRONZE Quality Awards                                            Golden LivingCenter – Walker
Arbor Gardens of Eyota                                           Golden LivingCenter – Whitewater
Benedictine Health Center                                        Golden Valley Rehabilitation and Care Center
Benedictine Health Center at Innsbruck                           Good Samaritan Society – Ambassador
Benedictine Health Center of Minneapolis                         Good Samaritan Society – Comforcare
Benedictine Living Community of St. Peter                        Good Samaritan Society – Inver Grove Heights
Bethel Care Center                                               Good Samaritan Society – St. Peter
Birchwood Arbors
                                                                  Good Samaritan Society – Stillwater
Birchwood Health Care Center
                                                                  Good Samaritan Society – University Specialty Center
Bridges Care Community
                                                                  Good Samaritan Society – Winthrop
Cambridge Health Care Center
                                                                  Grand Meadow Healthcare Center
                                                                  Health and Rehabilitation Center of New Brighton
                                                                  Karlstad Healthcare Center
                                              Residents from
                                              Villa Health        Mala Strana Health Care Center
                                              Care Center         May Creek Senior Living Campus
                                              (Mora) are          Meadows Assisted Living of Karlstad
                                              pleased with        Minnesota Masonic Home Assisted Living
                                               their 2011
                                               AHCA/NCAL          Northome Healthcare Center
                                                Bronze Quality    Old Main Village
                                                Award.            Park Gardens of Fergus Falls
                                                                  Park Health and Rehabilitation Center
                                                                     Prairie View Healthcare Center
                                                                     Red Wing Health Center
                                                                     Richfield Health Center
                                                                     Ridgeview Place
                                                                     River Grand Senior Living
                                                                     Robbinsdale Rehabilitation and Care Center
                                                                     Saint Anne of Winona
                                                                                     continued



St. Anthony Health Center                                                          Texas Terrace Care Center
St. Eligius Health Center                                                          The Colony at Eden Prairie
St. Isidore Health Center                                                          The Commons on Marice
St. Michael’s Health & Rehabilitation Center                                       Villa Health Care Center
St. Raphael’s Health & Rehabilitation Center                                       Woodbury Estates
Southview Acres Health Care Center                                                 Woodbury Health Care Center
Sterling Park Commons                                                              Woodbury Villa
Sterling Park Health Care Center                                                   Woodlyn Heights Health Care Center
Temperance Lake Ridge Senior Housing
                                                                                   SILVER Quality Awards
                                                                                   Andrew Residence
  Care Providers of Minnesota is proud to recognize                                Cerenity Senior Care of White Bear Lake
  Minnesota’s AHCA/NCAL senior and master quality                                  Golden LivingCenter – Chateau
  award examiners.
                                                                                   Golden LivingCenter – Greeley
  These individuals committed a significant amount of                              Golden LivingCenter – Henning
  time reviewing award nominations at the national                                 Golden LivingCenter – Hillcrest of Wayzata
  level. Spending between eight and ten hours per                                  Golden LivingCenter – Linden
  application, these examiners reviewed an average of
  eight applications, providing feedback, as well as                               Golden LivingCenter – Otter Tail Lake
  identifying strengths and areas for improvement for                              Golden LivingCenter – Wabasso
  award applicants.                                                                Good Samaritan Society – Albert Lea
                                                                                   Green Lea Manor – Mabel
   Thank you for your commitment to quality!                                       St. Benedict’s Senior Community
                                                                                   St. Brigid’s at Hi-Park
     Brooke Viegut                Joel Hartmann
     Chris Boldt                  Julie Ludwig                                     St. Lucas Care Center
     Chris Krebsbach              Julie Vettleson                                  St. Mary’s Care Center
     Christina Gamaldi            Karen Ruda                                       The Meadows of Mabel
     Christine Bakke              Kelsey Callahan
     Dawn Chiabotti               Marilyn Reierson
     Doug Beardsley               Mark Anderson                                    GOLD Quality Awards
     Fred Struzyk                 Mark R. Cairns                                   Lewiston Villa
     Gail Geisenhoff              Mary “Lisa” Harrel                               Madonna Living Community
     Glenora A. Souther           Nancy Moser
                                                                                   St. Gertrude’s Health & Rehabilitation Center
     Jeri Reinhardt               Sharon Thole
     Jill Brown                                                                    Villa St. Vincent/The Summit/Good Shepherd Hall




                                                                                                                 In 1997….
                                   Bronze              Silver        Gold                                        Hillcrest Rehabilitation
                                                                                                                 and Health Care Center
30                                                                                                               and Innsbruck Health
25                                                                                                               Care Center were the first
20                                                                                                               Minnesota members to
15                                                                                                               receive a Step 1 (now
10                                                                                                               Bronze) AHCA/NCAL
 5                                                                                                               Quality Award.
 0
      1997

             1998

                    1999

                           2000

                                  2001

                                         2002

                                                2003

                                                       2004

                                                              2005

                                                                     2006

                                                                            2007

                                                                                     2008

                                                                                            2009

                                                                                                   2010

                                                                                                          2011
- Brian S. Lassiter, President, Minnesota Council for Quality


                                                       The Baldrige Criteria for Performance Excellence may indeed be
                         1                             a little complex and sometimes difficult to interpret. But there’s
        Is your organization any good?                 wisdom in boiling it down to its central core by asking yourself
                                                       three easy questions: is your organization any good, is it getting
                         2                             better, and how do you know?
               Is it getting better?                   If you can’t answer any of them–or if you can’t answer them
                                                       consistently throughout the organization–you probably have room
                         3                             to improve.
               How do you know?
                                                       And now there are ways to ask yourself those questions
                                                       without having to invest a lot of time and money.


It has been said that the Baldrige framework (used by the        “Cadillac” Minnesota Quality Award (which is the most
American Health Care Association and the National Center         comprehensive, thorough evaluation of an organization’s
for Assisted Living (AHCA/NCAL) for their quality program)       operating system) to two “short cut” assessment processes
is highly complex, which is the reason some leaders give         that are entry level evaluations that help identify and priori-
for not using it to optimize their organization’s resources      tize improvement opportunities. (But more on that later.)
and improve outcomes. But I often reflect on a quote from
Dr. Harry Hertz, director of the Baldrige Performance Ex-        Let’s look at those three simple questions and see how
cellence Program, that translates Baldrige into three very       they translate the leading edge of validated management
simple, yet powerful, questions. They are: 1) Is your or-        practice.
ganization any good? 2) Is it getting better? And, 3) How
do you know?                                                     IS YOUR ORGANIZATION ANY GOOD?
                                                                 This question implies that continuous improvement
  If you can answer those questions definitively,                requires data: leaders need measures and information to
  your organization would be well on the way to                  determine if strategies are being effectively executed, if
  achieving higher performance and sustaining                    offerings are satisfying customer/stakeholder require-
  superior outcomes.                                             ments, if employees are competent and engaged, and if
                                                                 systems and processes are delivering value to stake-
We’ll delve into each question, but first, I need to offer       holders. In fact, in high performing organizations, most
some quick commentary on the Baldrige framework itself.          decisions are fact-based: rather than relying on intuition
                                                                 and gut (which will lead to inconsistent decision making
Created by law in 1987, the Baldrige program exists              and unsustainable performance), high performing
to help organizations improve results and achieve perform-       organizations use data to diagnose problems, make
ance excellence. The “Criteria for Performance Excel-            decisions, adjust resources, and improve processes.
lence” are revised every two years by studying high
performing organizations in all industries to determine what     However, it’s amazing to me how many organizations have
they are doing to reach superior levels of performance,          not taken the time to determine what is important to their
and those practices become future years’ Criteria.               overall success! By selecting, collecting, aligning, and inte-
                                                                 grating data and information to track daily operations AND
As such, the Criteria represent what’s been referred to as       overall organizational performance, then—and really only
the “leading edge of validated management practices,” a          then—will leaders have a handle on whether the organiza-
collection of best practices against which any organization      tion is any good. Performance measures should reflect a
can gauge its own performance, make adjustments, and             balanced perspective of different organizational and stake-
focus their resources on the highest leverage improvement        holder needs. Tools like the balanced scorecard help lead-
opportunities.                                                   ers to identify metrics that represent success along many
                                                                 different dimensions, including financial/budgetary and
And many do. My organization, the Minnesota Council for          market performance; customer-focused outcomes; work-
Quality, offers three assessment processes, from our             force-focused outcomes; leadership, governance, and stra-
                                                         continued


tegic outcomes; product, service, program outcomes; and          and speculation. By simply using metrics to determine
process, operations measures. Pick measures that reflect         what to improve and then monitoring progress and making
organizational priorities and key stakeholder expectations,      adjustments as you go, you will begin to create a culture
and once you have those measures, organizations should           focused on innovation, fact-based improvement, account-
use them!                                                        ability, and transparency. You’ll also be creating a true
                                                                 learning organization, in which key decisions are made
You should:                                                      based on data…and in which improvements, adjustments,
   A) Review them regularly and systematically and               and action are rooted in measurement and analysis rather
   across all levels of the organization (which requires         than conjecture and guesswork.
   making them accessible and available to anyone that
   needs them). Analyze performance to assess organiza-          IS YOUR ORGANIZATION GETTING BETTER?
   tional success, competitive performance, financial            Once you have your metrics in place, and as part of the
   health, progress relative to strategic objectives and         analysis an organization regularly conducts, the Baldrige
   action plans, and the organization’s ability to respond       Criteria suggest that leaders should consider levels of
   rapidly to changing organizational needs and chal-            performance for each of the key metrics, as well as trends
   lenges in your operating environment. In short, data          of those metrics—which are performance levels over time.
   should be the foundation of leadership meetings, staff        If trends are favorable, you can determine how to sustain
   meetings, board discussions, and anyplace else where          (or accelerate) performance. However, if trends are unfa-
   key decisions are being made.                                 vorable, you can determine how to adjust processes and/
                                                                 or resources to reverse the unfavorable trend or change
   B) Take action! Use the organizational review findings        the trajectory. Without trend information, leaders really
   to develop priorities for improvement and opportunities       cannot determine how performance looks over time, and
   for innovation. Deploy improvement efforts across work        therefore may make decisions inconsistent with the direc-
   groups and functional-level operations throughout the         tion and speed of desired change.
   organization (and to suppliers and partners, as appro-
   priate). Share lessons learned and best practices             HOW DO YOU KNOW?
   across units and work processes. Measures are only            I believe the last question relates to two very important
   useful if they inform decision making, and deci-              concepts. First, your performance data needs to be framed
   sions are only useful if they are acted upon.                 in the context of your key stakeholders. Organizational
                                                                 “goodness” really only can be defined by your stake-
It’s true that many organizations take action to improve         holders: your customers (clients, students, patients, etc.),
performance, but many do so using a great deal of intuition                                            continues on page 14




  Giddy-up! Julyfest at St. Brigid's at Hi-Park (Red Wing) features fireworks, music, carnival games, a parade, horseshoes
  and other fest-like activities. The event begins after dinner with live music and then moves outside (weather permitting).
  Residents, tenants, staff and family members are invited to this annual summer event.
                                                        continued


your workforce, and your partners. And you’ll never know if    Here’s a simple example of how comparative data can
you’re any good unless stakeholders tell you that you are.     be powerful, from a manufacturer I visited recently. The
So the first insight regarding the “How do you know” ques-     company was extremely proud of the fact that they had
tion is: you have to ask your stakeholders how you’re do-      reduced a certain type of production error by 10% for the
ing. Use surveys, focus groups, one-on-one meetings            last six months. This type of error has a direct and mean-
(systematically captured and aggregated) to determine          ingful impact on their gross margin and presumably their
satisfaction, engagement, and loyalty—to get feedback on       customer satisfaction, so any reduction should be rightfully
how you are doing to respond to stakeholder needs. Ask-        celebrated. But I asked them how their error rate now
ing your stakeholders allows you to definitively answer the    compared to the industry, simply wondering if they could
question “How do you know?”                                    determine if they’ve reduced it enough. They really had no
                                                               answer…they had no idea how their performance
The second insight embedded in this question is the notion     compared in the marketplace.
that all of your key metrics should have comparative data
associated with them. In order for leaders to determine the    A few weeks went by when their VP of Operations called to
organization’s relative performance, performance for           thank me for my question. They did some digging and
similar activities and processes—inside or outside an          determined that their 93.5% accuracy rate lagged their
organization’s industry—should be collected and used to        competitors. The best performance was 99.2% (from a
determine competitive gaps and to set goals. (Rather than      company that had much higher market share—
setting arbitrary performance targets, why not use the top     coincidence?), and the industry average was 94.5%. So,
quartile or best-in-class as a stretch goal?) Comparative      while they were proud of their 10% improvement, their
data allow organizations to understand current dimensions      performance was, well, average.
of world class performance, to see what’s possible, and to
encourage discontinuous or “breakthrough” performance.         Having this simple comparative data allowed them to
                                                               understand what was possible in their industry. Rather
                                                               than being content with modest improvement trends, they
Residents bring out their inner patriotism as they             set a new goal of 95% accuracy within a year, 97% within
celebrate Veteran’s Day.
                                                               two years, and a stretch goal of 99.5% within three years
                                                               to beat their competition. Furthermore, they are now
                                                               researching the connection between accuracy rates and
                                                               customer satisfaction, and believe they have found a fairly
                                                               tight correlation. Their ability to answer the simple question
                                                               “How do you know?” (if they are any good) will positively
                                                               impact customer satisfaction and profitability.

                                                               As previously mentioned, the Minnesota Council for
                                                               Quality now has two “short cut” assessment processes
                                                               available to any organization wanting the benefit of the
                                                               proven Baldrige Criteria, but not the rigor of a full-blown
                                                               Award assessment. One is consultant-facilitated (using a
                                                               Baldrige expert, jointly selected by the Council and the
                                                               organization) and involves a series of three diagnostic
                                                               discussions with senior leaders to identify improvement
                                                               priorities. The other is a self-assessment that uses a
                                                               survey-based instrument (Baldrige Express, which is
                                                               administered by the National Council for Performance
                                                               Excellence in Vermont) to aggregate and segment the
                                                               perspective of your workforce on the enterprise’s perform-
                                                               ance. This process takes about two hours to complete and
                                                               outlines your improvement opportunities through the
                                                               collective lens of those who operate the organization’s
                                                                                                        continues on page 19
Five Minnesota nursing homes are participating in a              nursing homes must have an acceptable QAPI plan in
demonstration project to determine the issues involved           place within a year after new QAPI regulatory standards
in implementing a comprehensive quality assessment and           are issued. CMS must provide best practice information
performance improvement (QAPI) program, and to                   and tools to assist nursing homes in implementing the
evaluate related tools, training resources, and technical        new expectations.
assistance to help with implementation.
                                                                 The existing quality assessment and assurance provision
 Minnesota is the only state with five facilities in the         mandates a quality assurance committee to “develop and
 project. These participants (all volunteers) are:               implement appropriate plans of action to correct quality
   Benedictine Health Center in Duluth*                          deficiencies,” but did not specify how to implement the
   Ecumen Parmly LifePointes in Chisago City                     regulation, nor did it call for active, data-driven perform-
                                                                 ance improvement. It is anticipated the new QAPI require-
   Good Samaritan Society—Ambassador in New Hope*
                                                                 ments will go into effect in 2013–2014.
   Perham Memorial Hospital and Home
   Sterling Park Healthcare Center in Waite Park                 CMS has outlined five required elements of a QAPI
   (Tealwood Care Centers)*                                      program: 1) Engage residents and all staff in defining
 *indicates a Care Providers of Minnesota member
                                                                 quality issues; 2) Monitor and interpret feedback on quality;
                                                                 3) Set priorities for more intensive team-based perform-
The demonstration project involves 17 long-term care             ance improvement projects; 4) Use root cause analysis to
facilities in four states (California, Massachusetts, Florida,   identify underlying reasons for quality challenges; and 5)
and Minnesota) and is part of a broader effort funded by         When indicated, make systemic changes to prevent prob-
the Centers for Medicare and Medicaid Services (CMS).            lems that occur because of the systems of care.
The state policy and nursing home environments differ in
each of the four states.                                         In many ways, Minnesota has a head start because we
                                                                 have a five-year history of providing incentives for nursing
In September 2010, CMS contracted with Stratis Health            homes to conduct systematic performance improvement
and the University of Minnesota to design and implement          activities, and have provided root cause analysis training
the demonstration project, led by Rosalie A. Kane, Ph.D.,        opportunities.
Division of Health Policy and Management. As part of the
demonstration project, the nursing homes will conduct a          For now, long-term care facilities are encouraged to begin
self-assessment to determine their specific needs. From          preparing for QAPI mandates by reviewing language on
there, they will have the opportunity to access a robust         the QAPI elements, discussing QAPI at the level of boards
resource library of online training modules, QAPI-related        of directors and corporate leadership, preparing their own
tools, evidence-based and best practice case studies, and        staff, engaging other stakeholders (such as family
other resources to help develop and manage their own             members and residents), and identifying new opportunities
QAPI program.                                                    for improvement.

A QAPI project liaison will provide technical assistance and      Two friends, from Culture Crossing the Generations,
help each facility monitor their progress. The 17 nursing                                              a collaboration
                                                                                                       between the
homes will also attend Learning Collaborative meetings to                                              SUMMIT Assisted
exchange ideas and experiences, and provide feedback                                                   Living at Villa St.
about the materials, successes, and challenges of the                                                  Vincent and the
implementation process.                                                                                University of
                                                                                                       Minnesota–
                                                                                                       Crookston, flash
QAPI in nursing homes is mandated by the Affordable                                                    ‘peace-out signs.
Care Act, which passed in March 2010, and requires that
                                                                                                          The collaboration
                                                                                                          partners seniors
                                                                                                          with ESL
 DID YOU KNOW...AHCA/NCAL’s Silver Quality Award                                                          students.
 criteria are very closely aligned with the CMS elements
 of a successful QAPI program.
Care Providers of Minnesota continues to engage, edu-            nursing home rate equalization (a government-imposed
cate, and encourage its membership to get involved in            cap of charging the same rate to private pay as Medicaid
advocacy at the national and state level.                        pays, in like settings). Members testified in committee,
                                                                 attended hearings, and participated in our rolling days at
Our national advocacy efforts in 2011 included sending           the Capitol in an effort to change this policy. In the end,
hundreds of letters to congress, hosting facility tours, par-    this provision was ultimately included in the omnibus bill,
ticipating in the AHCA/NCAL Political Action Committee           but the Governor vetoed the proposal.
(PAC), and attending the annual congressional briefing.
State efforts resulted in hundreds of visits with legislators,   Housing and elderly waiver issues
phone calls, emails, facility tours, increased PAC participa-    For housing members, the challenges were both regulatory
tion, letters to the editor, a YouTube video, and a rally.       and financial. While we continue to make progress educat-
Care Providers of Minnesota also worked with a myriad of         ing legislators about housing with services, a perennial
federal agencies this year from the Centers for Medicare         obstacle is their perceived value (legislators recognize and
and Medicaid Services (CMS) and the Department of                value nursing homes in their district, but housing with ser-
Labor to the State Attorney General, Department of Health,       vices does not hold that same “protected” status).
Department of Human Services, and Department of Em-
ployment and Economic Development.                               This year’s challenges were the sheer number of new leg-
                                                                 islators to talk to, the budget deficit, and the “cone of si-
Federal issues                                                   lence” (closed-door sessions) during the final budget nego-
There are issues we advocate for individually; and others        tiations. Ultimately the bills that passed during the “cone of
where we partner with our national affiliate (AHCA/NCAL),        silence” included mandatory transitional consultation—an
and/or other organizations. This year, we advocated on           item that was never introduced during the session and
issues such as the Elder Justice Act; the age restrictions       never discussed in committee or otherwise!
on using mechanical lifts; inappropriate use of hospital
observation days; the Community First Choice Option              Although there were rate cuts to the housing members, our
proposed rule; 2012 Medicare payment rates for skilled           member advocacy of testifying and letter writing, along
nursing facilities; and the proposed regulation to ensure        with other grassroots efforts, managed to reduce the cuts
Medicaid recipients have access to health care services.         dramatically. We will continue to educate lawmakers on
                                                                 the impact of their decisions on housing providers, tenants,
Nursing homes rates and policy                                   and caregivers.
Following the mantra of “you can’t legislate quality—you
have to fund it,” we successfully defeated the proposal to       Regulatory issues
cut nursing home rates, and because of our advocacy, the         Every year we bring the legislature ideas on ways to
House took a strong position against rate cuts to nursing        reduce or change regulations (administrative and legisla-
homes, and ultimately got some increases to the lowest           tive) and some ultimately succeed. This year, we were
reimbursed facilities!                                           successful in passing language that requires the local
                                                                 agency to process a Medical Assistance (MA) application
We continued the great debate concerning the policy of           within ten working days; electronic transmission of inter-


 Rolling Days at the Capitol provide an opportunity for members to meet with their legislators and talk about the budget
 and how policy proposals impact their facilities, staff, and residents.
                                                       continued




  R-E-S-P-E-C-T was our rally theme over at the Capitol in St. Paul. Over 600 members and supporters of long-term care,
  decked out in orange t-shirts, showed their solidarity and support at our first outdoor rally!


state CNA registry endorsements; delay of the elevator             Fact Card 1: Economic Impact of Long-Term Care
upgrade requirements for another three years; and the              Fact Card 2: Rate Equalization
creation of a work group to evaluate and make recommen-            Fact Card 3: Caregivers
dations on the elimination of redundant, unnecessary and
                                                                   Fact Card 4: Home and Community Based Services
obsolete state mandated reporting or data submittal
                                                                   Fact Card 5: Nursing Homes
requirements for health care providers.
                                                                   Fact Card 6: The Cost of Caregiving
Legal strategy                                                     Fact Card 7: Financing Reform
Our advocacy had an additional wrinkle as a result of the
government shutdown. We had to create a legal strategy        New this year was our use of a video after session ad-
to combine with our legislative efforts, focusing on who      journed. Because much of the post-session negotiating
should be funded during the shutdown.                         was done behind closed doors, we created a simple, but

To ensure that our members’ operations and payments                                                  continued on page 18
continued, we pursued a legal strategy while maintaining a
strong legislative advocacy. We were successful in arguing
                                                                     Advocacy efforts at the state and national level are
before Ramsey County Chief Judge Kathleen Gearin that
                                                                     vital to long-term care. Congressman Tim Walz and
payments to long-term care providers were an “essential”             Dave Kyllo, NCAL’s executive director, are all smiles
function of core government and that payments to provid-             at a Golden LivingCenter event.
ers must be continued. (The original recommendation from
the governor’s office was to NOT pay providers of Medi-
caid services—our brief and testimony helped to amend
the position from the administration.) We also successfully
argued before the Special Master that employee back-
ground check processing and the Nursing Assistant Regis-
try were essential. These legal efforts were designed to
make the shutdown as painless as possible for providers.

Our toolbox
Again this year, staff helped develop materials for mem-
bers to use with legislators. The use of the materials
helped to educate the newest members of the House and
Senate and frame the debate. Seven fact cards were de-
veloped and rolled out over the course of the Session:
                                                         continued


powerful, “Value My Care” video which was used to help               -term care financing reform acknowledges the need
tell our story. Members sent in photos of staff, residents,          for Minnesotans to plan ahead, using a variety of
and family members holding signs with messages. The                  mechanisms to finance their own long-term care ser-
photos, interspersed with facts, created a compelling                vice and support needs.
video. The link to the video was sent to the negotiators,
                                                                Care Providers of Minnesota had a challenging year for
and members were encouraged to send the video link to
                                                                advocacy. It was due to the actions of members and
their legislator. This method was very successful, as meas-
                                                                the creation of tools by our staff that we were able to
ured by the number of legislators who commented on the
                                                                effectively advocate and educate decision makers
video, as well as the number of “hits” to the site.
                                                                about the future of older adult services.

Moving forward
Our ongoing advocacy efforts work toward preparation for
the future as well as providing for today’s needs. In this,
                                                                 Data suggest that nursing facilities represent the lowest-
Care Providers of Minnesota advocates that Minnesotans           cost institutional setting. As policymakers consider how
should view the planning for, and the financing of, their        to pay based on patient characteristics rather than the
own long-term care needs as an obligation; policymakers          setting of care, measuring patient outcomes and adjust-
need to establish mechanisms that both encourage and             ing for patient severity becomes increasingly important.
reward that behavior. Individuals should not have to impov-      Long-term care settings may provide policymakers with
erish themselves in order to receive some measure of help        an opportunity to shift high acuity patients to nursing
with the services and care they need.                            facilities, with the goal of lowering program payments. In
                                                                 making this decision, it will be critical to learn whether
Our advocacy uses a menu of strategies to assist individu-       the outcomes that nursing facilities are able to achieve
                                                                 for similar patients at these lower payment rates are
als to start saving for their long-term care needs. These
                                                                 comparable to the outcomes achieved at higher cost
strategies include tax incentives for personal savings, pool-
                                                                 settings of care.
ing risk to make purchasing long-term care insurance more
affordable, and consumer education.                              Research can begin to assess outcomes and patient
                                                                 care across settings. Additional analyses for patient
We advocate for policies that:                                   conditions and the inclusion of post-hospitalization set-
    Create incentives to promote and reward personal             tings will be highly useful in developing a more complete
    responsibility for privately paying consumers.               picture of the value of nursing facility services in the
                                                                 post-acute care continuum. In addition to better under-
    Increase consumer literacy about long-term care              standing costs of care and outcomes for like patients
    financing through a collaborative campaign with busi-        across settings, researchers may define the patient care
    ness, consumer, and government groups.                       processes that lead to optimal outcomes, regardless
                                                                 of setting.
    Expand options for financing long-term care. Long


 Members from across the state participated in a “Value My Care” campaign which featured photos of staff and residents.
 The photos became a video advocacy tool directed toward legislators and decision makers. (To view the video, go to:
 www.youtube.com, and type in search box: Minnesota government shutdown: grandmas and grandpas speak out)
Developed in 2010 and released in 2011 by Care Providers of Minnesota’s Quality Council, the Dashboard
visually displays a variety of key quality measures:.




                                  from page 5                                                               from page 14

    Percent of home health episodes of care in which          processes: your workforce. One of our Council members
    interventions to prevent pressure sores were included     commented on the value of the self-assessment, “this was
    in the plan of care for at-risk patients (35th).          the easiest and most useful check-up my organization
                                                              could receive. We found several key areas to improve, and
Impact of improved performance                                are taking action to impact results. I recommend this to any
If Minnesota improved its performance to the level of the     organization.”
highest-performing state in the specific indicators where
                                                              If you or your organization are interested in learning more
the state did not rank the highest:
                                                              about any of our three Baldrige-based assessment
     7,895 more low- or moderate-income (<250%                processes and how they complement your efforts with
    poverty) adults age 21+ with activity of daily living     AHCA/NCAL or continuous improvement in general, drop
    disabilities would be covered by Medicaid.                me a line at brian.lassiter@councilforquality.org or visit our
     4,249 nursing home residents with low care needs         website at www.councilforquality.org.
    would instead be able to receive long-term services
    and supports in the community.                            Care Providers of Minnesota joined with the Minnesota
                                                              Council for Quality in a partnership arrangement in fourth
The complete report and state-specific data is available at   quarter 2011. Currently we are working on a variety of joint
www.longtermscorecard.org.                                    ventures to benefit members of both organizations.
Doug Beardsley, VP of member services
Todd Bergstrom, director of research & payment
Patti Cullen, CEO/president
Lisa Foss Olson, director of communications & PR
Toby Pearson, VP of advocacy




                          7851 Metro Parkway
                          Bloomington, MN 55425

                          www.careproviders.org

				
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